Kohler and Wright Journal of Pharmaceutical Policy and Practice (2020) 13:58

https://doi.org/10.1186/s40545-020-00256-w

COMMENTARY Open Access

The Urgent Need for Transparent and

Accountable Procurement of Medicine and
Medical Supplies in Times of COVID-19
Pandemic
Jillian Clare Kohler1* and Tom Wright2

Abstract
The COVID-19 pandemic has unleashed unprecedented and complex public policy issues. One that has emerged as
a challenge for many countries globally is how to ensure the efficient and effective procurement of quality medical
supplies. Existing corruption pressures on procurement—everything from undue influence to the outright bribery
of public officials—has been amplified by the pandemic, and thus demands commensurate policy responses. We
argue that transparency and accountability in procurement are essential to preventing the corruption risks that
threaten the health and well-being of populations.
Keywords: Procurement, Transparency, Accountability, Corruption, COVID-19, Health policy

Introduction Notably, “procurement is an underappreciated health

The COVID-19 pandemic has unleashed unprecedented
and complex public policy issues. One that has emerged
as a challenge for many countries globally is how to en-
sure the efficient and effective procurement of quality
medical supplies. During the pandemic, governments
have scrambled to secure, not only essential medicines,
but personal protective equipment (PPE), ventilators,
medicines, and diagnostics. A quick Google search
shows that this has even been the case in countries with
robust health systems, such as Canada, the United King-
dom, and Germany [1–3]. Urgency, demand, and short-
ages have placed new stress on global supply chains,
leaving them vulnerable to further disruption. As a re-
sult, the market-distorting effect of price gouging and
the dangerous purchasing of flawed and/or falsified
goods has already been observed in many countries.
* Correspondence: jillian.kohler@utoronto.ca
1
University of Toronto Leslie Dan Faculty of Pharmacy, 144 College Street,
Toronto, Ontario M5S 3M2, Canada
Full list of author information is available at the end of the article
system function…inefficiencies… leave some of the poor-
est countries paying some of the highest drug prices in
the world” [4]. Equally important, the procurement
process is one of the greatest risks for corruption among
all government functions [5].
Corruption is defined by the leading global anti-
corruption organization, Transparency International, as,
“the misuse of entrusted power for private gain” [6]. It is
a global phenomenon that manifests in different forms
and within all types of organizations [7]. Corruption can
foster inequities as it skews how resources are distrib-
uted and create access barriers to public services and
goods, such as essential medicines. Ideally, the good pro-
curement of pharmaceuticals supports access to essential
medicines for the population. Yet, when corruption infil-
trates the pharmaceutical procurement processes, health
goals can be threatened by possible consequences such
as pharmaceutical shortages, inflated drug prices, and
the distribution of falsified and substandard essential
medicines [7]. Procurement is thus critical to efforts by

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Kohler and Wright Journal of Pharmaceutical Policy and Practice
governments to ensure equitable access of essential
medicines for their populations, particularly during these
unprecedented times of the COVID-19 pandemic.
Corruption and procurement
Even in non-crisis times, reducing the risk of corruption
in public procurement is a challenge. This holds particu-
larly true for procurement in the health sector, given its
especially lucrative and technically complex nature. If re-
sources allocated to pharmaceutical procurement are
wasted due to corruption and operational deficiencies, not
only the pharmaceutical system is affected; the health sys-
tem as a whole loses out on effectiveness and equity. In
turn, the public may very well lose trust in governments
to deliver on their commitments such as ensuring access
of the population to essential medicines.
Publicly funded essential medicines are highly vulner-
able to corruption if there is weak governance in the pro-
curement system [7]. Savedoff and Grépin, accordingly,
describe corrupt activities that may take place in the
pharmaceutical procurement processes such as bribes for
inspectors; improper bidding procedures for purchasing;
diversion of the public drug supply to private practice;
kickbacks for referrals; and pharmacies or drug shops sell-
ing illegal items [8]. Ware et al. also explain how bribes or
kickbacks are common forms of corruption in public pro-
curement [9]. Corruption in procurement may be individ-
ual or systemic; in China, Rose-Ackerman and Yan
highlight how individuals with procurement responsibil-
ities may engage in corrupt behavior, while the govern-
ment at large may play a role by granting promotions to
physicians willing to make favorable procurement deci-
sions for firms with ties to the state [10].
Fraud in hospital procurement is also of particular risk
because of the technical expertise required to purchase
pharmaceuticals. Spending large sums of money on large
volumes of medicines and medical equipment, hospitals
have been the object of a wide range of corrupt activities,
including kickbacks in procurement and the delivery of ex-
pired and substandard products [11]. There have also been
several high-profile cases showing the widespread prolifera-
tion of kickbacks and bribes from pharmaceutical firms to
doctors to influence decisions over prescriptions and there-
fore procurements. For example, this year, Novartis paid
US$ 678 million to settle a fraud lawsuit, which detailed its
wide-reaching kickback program, to influence doctors to
prescribe specific medicines in the United States [12].
Corruption in procurement: COVID-19
Promising breakthroughs in COVID-19 medicines re-
search offer seemingly rare glimpses of hope in the fight
against the pandemic. For example, a University of Ox-
ford randomized clinical trial demonstrated the benefi-
cial use of dexamethasone, a generic drug, in improving
(2020) 13:58 Page 2 of 4
survival rates in COVID-19 patients with respiratory
complications [13]. Researchers also conducted success-
ful early clinical trials into a promising vaccine candi-
date, with the latest results demonstrating the vaccine’s
ability to induce a strong immune response [14]. Effect-
ive procurement of these products, and others, to treat
COVID-19 will depend on robust government procure-
ment practices. Past experience illuminates how corrup-
tion in pharmaceutical procurement can distort and
restrict equitable access to their life-saving properties by
increasing prices, facilitating the distribution of sub-
standard and falsified medicines, and creating shortages.
Corruption risks in procurement are even more pro-
nounced during times of emergency. During disaster re-
sponse, huge amounts of additional funding are directed
to rapidly resolve a critical and complex problem, often
through acquiring limited resources under large
amounts of pressure. An estimated US$ 16 trillion has
already been spent by governments globally on their re-
sponses to COVID-19 [15]. The massive amounts of
public funding that are allocated to procurement are not
to be overlooked. And what is more, existing corruption
pressures on procurement—everything from undue in-
fluence and/or bribery on public officials—are further
amplified by the pandemic. Efforts to rapidly procure ur-
gent goods may require flexibility, speed, and a level of
discretion that can further widen the risks of corruption.
Suppliers may exploit shortages to demand grossly in-
flated prices. Relaxed checks and balances can result in
the purchasing of sub-standard or falsified products,
which undermine health security and reduce confidence
in public institutions [16]. Unscrupulous politicians may
use the disruption to enrich themselves or their friends.
Examples of alleged corruption during the pandemic are
already bountiful in many countries. In an effort to procure
N95 face masks, the United States Federal Government
gave a direct award of US$ 55 million to a company that
had no experience in supplying medical supplies and no re-
corded employees [17]. In the UK, the government directly
procured 3.5 million testing kits, which later turned out to
be unusable [18], while a senior procurement official for
the National Health Service (NHS) in London was reported
to have traded PPE for private gain [19]. In Brazil, it was re-
ported that the Federal Government purchased masks from
a supplier with ties to President Jair Bolsonaro that were 67
percent more expensive than the other supplier bids in the
same procurement competition [20].
As COVID-19 threatens a global surge in substandard
and falsified products [21], it is even more important to
understand the complex enabling relationship corrup-
tion in procurement of medicines has with substandard
and falsified medicines. If proper procedures are not in
place, drug shortages can provide an opportunity for the
proliferation of substandard and falsified medicines [22].
Kohler and Wright Journal of Pharmaceutical Policy and Practice
Preventing corruption risks in procurement: The
role of transparency and accountability
How can we stop the pervasive risks of corruption that
threaten the health and well-being of populations? For
one, we need to ensure that there is transparency in the
whole of the procurement process. Transparency requires
information on procurement decisions that are publicly
available. This can allow prices paid for the same health
products to be compared across a local, regional, or na-
tional level and curb price gouging, price manipulation,
and overpayments. For example, a group of hospital trusts
as part of the United Kingdom’s National Health Service
(NHS) Southern Procurement Partnership collected and
standardized manufacturer and price data for generic
products that were being bought separately as individual
trusts [23]. These products included exam gloves and dis-
posable aprons. In comparing this data, they were able to
identify priority cost-saving opportunities which
amounted to 15-50% beyond current NHS best price for
these products [23]. An independent report went on to
say that if this data-sharing strategy was used across the
NHS, the NHS could save an estimated £500m [23]. Im-
portantly, data transparency can illuminate patterns of
normal procurement behavior and identify potential out-
liers indicative of overpayments, collusion, or kickbacks.
We need to ensure that even in this crisis, there are ac-
countability mechanisms in place that make governments
responsive to the people they serve. This means having
metrics to document what is being procured, why, where,
and for how much. In this, the role of civil society is crit-
ical. An empowered civil society can ensure that prob-
lems—corruption related or otherwise—are not swept
under the rug. Without this, the effectiveness of the lim-
ited resources mobilized to respond to the pandemic will
be undermined. If corruption risks are not addressed, they
will ultimately result in further loss of life. Public procure-
ment is a complex and often ignored subject, but its impli-
cations for the health of citizens is significant. Failing to
properly address the corruption risks in the public pro-
curement of medicines will severely undermine the effect-
iveness of the global COVID-19 response.
Abbreviations
NHS: National Health Service (United Kingdom); OECD: Organisation for
Economic Co-operation and Development; PPE: Personal protective
equipment
Acknowledgements
Research assistance was provided by Anna Wong.
Authors’ contributions
Jillian Clare Kohler led the first draft of this article. Tom Wright provided
substantial inputs and edits to the article. The author(s) read and approved
the final manuscript.
Authors’ information
Jillian Kohler is a Connaught Scholar and Professor at the University of
Toronto Leslie Dan Faculty of Pharmacy, and Director of the World Health
(2020) 13:58 Page 3 of 4
Organization Collaborating Centre for Governance, Accountability, and
Transparency in the Pharmaceutical Sector. Tom Wright is a Senior Research
and Advocacy Officer with anti-corruption NGO Transparency International,
where he leads the organization’s efforts to promote open contracting in
health procurement.
Funding
This paper was partially supported by a Leslie Dan Faculty of Pharmacy,
University of Toronto Clinical, Social and Administrative (CSAP) Pharmacy
grant to Jillian Kohler. This article was supported by funding from the Leslie
Dan Faculty of Pharmacy New Initiative and Innovation Award.
Availability of data and materials
Data sharing is not applicable to this article as no datasets were generated
or analyzed during the current study.
Ethics approval and consent to participate
Not applicable.
Consent for publication
Not applicable.
Competing interests
The authors declare that they have no competing interests. Tom Wright is a
full-time employee of the Transparency International Health Initiative, which
receives funding from GlaxoSmithKline, the Open Society Foundation, and
the UK Department for International Development.
Author details
1
University of Toronto Leslie Dan Faculty of Pharmacy, 144 College Street,
Toronto, Ontario M5S 3M2, Canada. 2Transparency International UK, 10
Queen St Pl, London EC4R 1BE, UK.
Received: 17 July 2020 Accepted: 18 August 2020
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